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. Author manuscript; available in PMC: 2021 Jan 13.
Published in final edited form as: J Card Surg. 2020 Jul 28;35(9):2432–2435. doi: 10.1111/jocs.14817

Early failure after non-resectional mitral valve repair with artificial chordae

Ryan A Moore 1, Per Wierup 1, Daniel J P Burns 1, A Marc Gillinov 1
PMCID: PMC7804967  NIHMSID: NIHMS1658912  PMID: 32725653

Abstract

Severe recurrent mitral regurgitation within 1 year of mitral valve repair is usually attributed to a technical issue with the original repair procedure. However, when artificial chordae are employed to correct mitral valve prolapse, ventricular remodeling (ie, decreased ventricular size) can lead to recurrent prolapse and valve dysfunction. To illustrate this phenomenon, we present two patients who experienced early failure after undergoing mitral valve repair with artificial chordae.

Keywords: early failure, mitral valve repair, mxyxomatous mitral valve, neochordae

1 |. INTRODUCTION

Degenerative mitral valve (MV) disease is the most common indication for MV surgery in North America.1 In such patients, MV repair is preferred over MV replacement.2–4 Historically, resectional techniques described by Carpentier5 were the predominant approach to MV repair.

David and Frater6–8 originally described the used of artificial ePTFE chords to reconstruct the MV apparatus when ruptured or elongated native chordae are the cause of prolapse. MV repair with artificial chordae has excellent mid- and long-term outcomes.9,10 It has been shown to produce equivalent clinical outcomes when compared with resectional techniques. Potential advantages when compared with resectional techniques include preservation of the MV apparatus, greater surface of leaflet coaptation and decreased risk of systolic anterior motion (SAM).11,12 However, a small percentage of patients experience early MV repair failure after repair with artificial chordae.

We report two cases of recurrent mitral regurgitation early after MV repair with artificial chordae; these were attributable to recurrent prolapse resulting from left ventricular remodeling.

2 |. CASE SERIES

2.1 |. Approach to artificial chordae implantation

An ePTFE suture (CV-4) is passed through the fibrous region of a papillary muscle on the same side of the valve (ie, medial or lateral) as the region of prolapse. Each end of the suture is brought up to the leaflet edge and passed twice through the leaflet tissue in the region of prolapse; the needles pass from the ventricular to the atrial aspect and finish adjacent to each other on the atrial aspect. The chordal length is adjusted to a level to prevent prolapse, using the region of A1-P1 as a reference point and ensuring a generous zone of coaptation. The suture is tied on the atrial side of the MV leaflet.13 All repairs include a posterior annuloplasty band.

2.2 |. Case 1

A 42-year-old male presented with 4+ mitral regurgitation (MR), annular dilatation, mild left ventricular dilatation, and mild left ventricular dysfunction. At index operation he had extensive posterior leaflet prolapse with ruptured chordae to P2/P3. Two sets of artificial chords were fixed to the posterior leaflet and a 35-mm annuloplasty band placed. No SAM or MR was noted after the case, and leaflet coaptation was excellent. Three months postoperative, he presented with 3 to 4+ MR and mild symptoms. At reoperation, previously placed chords remained intact but he had P2 prolapse with a noticeably remodeled ventricle that was now normal in size. His valve was repaired with sliding valvuloplasty.

2.3 |. Case 2

A 51-year-old male presented with 4+ MR, LV dilatation, and mild biventricular dysfunction. At index operation he had multiple ruptured chords to his posterior leaflet. Artificial chords were fixed to the posterior leaflet and a 35-mm annuloplasty band was placed. He presented 6 months later with 4+ MR and NYHA Class II symptoms; his ventricular function had improved and ventricular size was now normal. At reoperation, artificial chords remained intact but were now too long, causing posterior leaflet prolapse. His valve was repaired with sliding valvuloplasty.

3 |. DISCUSSION

When compared with MV replacement, MV repair in patients with degenerative disease is associated with superior outcomes and, in addition, excellent durability.14 However, there is an inherent failure rate after MV repair.15,16 Failure within 1 year of repair is traditionally attributed to technical error rather than to disease progression or new pathology.17 Non-resectional techniques including the use of artificial chordae have potential advantages over leaflet resection stemming primarily from preservation of MV physiology.18 Here we describe our experience with two patients who required early reoperation for recurrent mitral regurgitation after MV repair using artificial chordae.

In patients with left ventricular dysfunction and enlargement, MV repair can be associated with reverse remodeling that includes a reduction in left ventricular dimension (Figure 1). We suggest here that revere remodeling after MV repair may occasionally result in ventricular morphology that causes recurrent prolapse in patients whose initial MV repair was achieved with the application of artificial chordae. Further study of a larger number of patients will be necessary to understand the precise changes in ventricular dimension that can cause recurrent prolapse when artificial chordae are employed.

FIGURE 1.

FIGURE 1

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Reverse ventricular remodeling after mitral valve (MV) repair with artificial chordae. A, Short axis view depicting the presence of ventricular dilatation after initial MV repair. B, Short axis view of remodeled left ventricle at time of reoperation that is normal in size. C, Long axis view of successful initial repair. D, Long axis view of remodeled left ventricle at time of reoperation with evidence of posterior prolapse. E, Four-chamber view of successful initial MV repair without evidence of prolapse. F, Four-chamber view before reoperation with presence of recurrent jet and recurrent posterior prolapse

Determination of proper chordal length during surgery remains crucial in successfully performing artificial chord repair. We routinely utilize artificial chords using either the free-hand or pre-measured loop techniques with great success.19 We suggest the mechanism of early failure described here represents an inherent risk of correcting mitral regurgitation in patients who have left ventricular dilatation and dysfunction rather than a technical failure. Reverse ventricular remodeling may result in recurrent prolapse in such patients. One option is to create chords that are somewhat shorter in patients with ventricular dilatation, anticipating the possibility of remodeling. A second option is to employ resectional techniques in such patients.

Acknowledgments

DISCLOSURES

Dr. Gillinov discloses a financial relationship with Edwards Lifesciences, Medtronic, Abbott, CryoLife, ClearFlow, Johnson and Johnson and Atricure. Dr. Wierup discloses financial relationships with Edwards Lifesciences, Medtronic and CryoLife.

REFERENCES

  • 1.Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29–e322. [DOI] [PubMed] [Google Scholar]
  • 2.Gillinov AM, Cosgrove DM, Blackstone EH, et al. Durability of mitral valve repair for degenerative disease. J Thorac Cardiovasc Surg. 1998; 116(5):734–743. [DOI] [PubMed] [Google Scholar]
  • 3.Mohty D, Orszulak TA, Schaff HV, Avierinos JF, Tajik JA, Enriquez-Sarano M. Very long-term survival and durability of mitral valve repair for mitral valve prolapse. Circulation. 2001;104(12 suppl 1): I1–I7. [DOI] [PubMed] [Google Scholar]
  • 4.Suri RM, Schaff HV, Dearani JA, et al. Survival advantage and improved durability of mitral repair for leaflet prolapse subsets in the current era. Ann Thorac Surg. 2006;82(3):819–826. [DOI] [PubMed] [Google Scholar]
  • 5.Carpentier A. Cardiac valve surgery—the “French correction”. J Thorac Cardiovasc Surg. 1983;86(3):323–337. [PubMed] [Google Scholar]
  • 6.Frater RW, Berghuis J, Brown AL Jr., Ellis FH Jr. The experimental and clinical use of autogenous pericardium for the replacement and extension of mitral and tricuspid value cusps and chordae. J Cardiovasc Surg. 1965;6(3):214–228. [PubMed] [Google Scholar]
  • 7.David TE. Replacement of chordae tendineae with expanded polytetrafluoroethylene sutures. J Card Surg. 1989;4(4):286–290. [DOI] [PubMed] [Google Scholar]
  • 8.Zussa C, Frater RW, Polesel E, Galloni M, Valfré C. Artificial mitral valve chordae: experimental and clinical experience. Ann Thorac Surg. 1990;50(3):367–373. [DOI] [PubMed] [Google Scholar]
  • 9.Falk V, Seeburger J, Czesla M, et al. How does the use of polytetrafluoroethylene neochordae for posterior mitral valve prolapse (loop technique) compare with leaflet resection? a prospective randomized trial. J Thorac Cardiovasc Surg. 2008;136(5): 1205–1206. [DOI] [PubMed] [Google Scholar]
  • 10.David TE, Bos J, Rakowski H. Mitral valve repair by replacement of chordae tendineae with polytetrafluoroethylene sutures. J Thorac Cardiovasc Surg. 1991;101(3):495–501. [PubMed] [Google Scholar]
  • 11.Perier P, Hohenberger W, Lakew F, Diegeler A. Prolapse of the posterior leaflet: resect or respect. Ann Cardiothorac Surg. 2015; 4(3):273–277. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Cetinkaya A, Bär S, Hein S, et al. Mitral valve repair for posterior leaflet prolapse: long-term comparison of loop implantation vs resection. J Card Surg. 2020;35(1):11–20. [DOI] [PubMed] [Google Scholar]
  • 13.Chemtob RA, Wierup P, Mick S, Gillinov M. Choosing the “Best” surgical techniques for mitral valve repair: lessons from the literature. J Card Surg. 2019;34(8):717–727. [DOI] [PubMed] [Google Scholar]
  • 14.Javadikasgari H, Mihaljevic T, Suri RM, et al. Simple versus complex degenerative mitral valve disease. J Thorac Cardiovasc Surg. 2018; 156(1):122–129. e16. [DOI] [PubMed] [Google Scholar]
  • 15.Flameng W, Herijgers P, Bogaerts K. Recurrence of mitral valve regurgitation after mitral valve repair in degenerative valve disease. Circulation. 2003;107(12):1609–1613. [DOI] [PubMed] [Google Scholar]
  • 16.Castillo JG, Anyanwu AC, Fuster V, Adams DH. A near 100% repair rate for mitral valve prolapse is achievable in a reference center: implications for future guidelines. J Thorac Cardiovasc Surg. 2012; 144(2):308–312. [DOI] [PubMed] [Google Scholar]
  • 17.Dumont E, Gillinov AM, Blackstone EH, et al. Reoperation after mitral valve repair for degenerative disease. Ann Thorac Surg. 2007;84(2): 444–450. [DOI] [PubMed] [Google Scholar]
  • 18.Athanasiou T, Chow A, Rao C, et al. Preservation of the mitral valve apparatus: evidence synthesis and critical reappraisal of surgical techniques. Eur J Cardiothorac Surg. 2008;33(3): 391–401. [DOI] [PubMed] [Google Scholar]
  • 19.Gillinov AM, Banbury MK. Pre-measured artificial chordae for mitral valve repair. Ann Thorac Surg. 2007;84(6):2127–2129. [DOI] [PubMed] [Google Scholar]

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